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The number of human milk banks is growing worldwide. The introduction of donor human milk (DHM) to neonatal units has been advocated as a strategy to promote maternal breastfeeding. However, concern has been raised that the introduction of DHM may actually lead to a decrease in maternal breastfeeding. To address this question, we conducted a systematic literature review of studies that assessed maternal breastfeeding rates before and after the introduction of DHM. We searched 7 electronic databases, carried out citation tracking, and contacted experts in the field. Where data for breastfeeding rates before and after the introduction of DHM were directly comparable, a relative risk was calculated. Our search identified 286 studies, of which 10 met the inclusion criteria. Definitions of patient populations and study outcomes varied, limiting meaningful comparison. Where possible, relative risks (RR) were calculated on aggregated data. The introduction of DHM had a significant positive impact on any breastfeeding on discharge (RR, 1.19; 95% confidence interval [CI], 1.06-1.35; P = .005) but none on exclusive maternal breastfeeding on discharge (RR, 1.12; 95% CI, 0.91-1.40; P = .27) or on exclusive administration of own mother's milk (OMM) days 1 to 28 of life (RR, 1.08; 95% CI, 0.78-1.49; P = .65). A single-center study demonstrated a significant decrease in the percentage of feeds that were OMM after the introduction of DHM. In conclusion, the available data demonstrate some evidence of positive and negative effects on measures of maternal breastfeeding when DHM is introduced to a neonatal unit.
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Journal title: Journal of Human Lactation
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Journal of Human Lactation
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DOI: 10.1177/0890334416632203
Donor human milk (DHM) is used in neonatal intensive care
units (NICUs) for the feeding of preterm infants when own
mother’s milk (OMM) is not available or insufficient. A
recent Cochrane review1 showed that in preterm and low
birth weight infants, feeding with formula compared with
DHM results in a higher risk of developing necrotizing
enterocolitis (NEC). As the incidence of NEC increases in
relation to the other complications of preterm birth,2 there is
growing interest worldwide in the use of DHM.
Currently, it is estimated that there are about 500 human
milk banks (HMBs) in existence in over 37 countries.3 In
addition, the number of HMBs is known to be growing
in countries with large populations such as India,4 and the
first HMB in Russia was recently established in Moscow.5
Donor human milk is currently recommended by the
World Health Organization (WHO),6 the American Academy of
Pediatrics (AAP),7 and the European Society for Paediatric
Gastroenterology Hepatology and Nutrition (ESPGHAN),8 as
the preferred alternative to OMM if this is not available for
low birth weight (WHO) or preterm (AAP, ESPGHAN)
infants. In the United States, the proportion of NICUs using
DHM increased from 25% in 2007 to 45% in 2011.9
Despite this, there remain many neonatal units that do not
use DHM, for a variety of reasons, including cost, uncer-
tainty about the evidence base for its use, and parental prefer-
ences.10 A 2014 survey of level 3 and 4 NICUs in the United
States10 showed that that 41% of respondents did not use
DHM for their patients. Similarly, a survey of special care
baby units, local neonatal units, and NICUs in the United
Kingdom,11 also carried out in 2014, showed that 39% of
respondents did not initiate infants on DHM.
If the use of DHM continues to increase, a key question is
how this may affect maternal breastfeeding rates. A national
XXX10.1177/0890334416632203Journal of Human LactationWilliams et al
1Simpson Centre for Reproductive Health, Edinburgh, UK
2Centre for Population Health Sciences, University of Edinburgh, UK
3Royal Hospital for Sick Children, Yorkhill, Glasgow, UK
4Newcastle Hospitals NHS Foundation Trust, Newcastle upon Tyne, UK
Date submitted: April 20, 2015; Date accepted: January 18, 2016.
Corresponding Author:
Thomas Williams, MRCP, Neonatal Unit, Simpson Centre for
Reproductive Health, Royal Infirmary of Edinburgh, 51 Little France
Crescent, Edinburgh EH16 4SA, UK.
Use of Donor Human Milk and Maternal
Breastfeeding Rates: A Systematic Review
Thomas Williams, MRCP1, Harish Nair, MD, PhD2,
Judith Simpson, MD3, and Nicholas Embleton, MD4[AQ: 1][AQ: 2][AQ: 3]
The number of human milk banks is growing worldwide. The introduction of donor human milk (DHM) to neonatal
units has been advocated as a strategy to promote maternal breastfeeding. However, concern has been raised that the
introduction of DHM may actually lead to a decrease in maternal breastfeeding. To address this question, we conducted
a systematic literature review of studies that assessed maternal breastfeeding rates before and after the introduction of
DHM. We searched 7 electronic databases, carried out citation tracking, and contacted experts in the field. Where data
for breastfeeding rates before and after the introduction of DHM were directly comparable, a relative risk was calculated.
Our search identified 286 studies, of which 10 met the inclusion criteria. Definitions of patient populations and study
outcomes varied, limiting meaningful comparison. Where possible, relative risks (RR) were calculated on aggregated data.
The introduction of DHM had a significant positive impact on any breastfeeding on discharge (RR, 1.19; 95% confidence
interval [CI], 1.06-1.35; P = .005) but none on exclusive maternal breastfeeding on discharge (RR, 1.12; 95% CI, 0.91-1.40;
P = .27) or on exclusive administration of own mother’s milk (OMM) days 1 to 28 of life (RR, 1.08; 95% CI, 0.78-1.49;
P = .65). A single-center study demonstrated a significant decrease in the percentage of feeds that were OMM after the
introduction of DHM. In conclusion, the available data demonstrate some evidence of positive and negative effects on
measures of maternal breastfeeding when DHM is introduced to a neonatal unit.
breastfeeding, donor human milk, milk banks
2 Journal of Human Lactation
survey in Italy showed that neonatal units associated with an
HMB have higher rates of maternal breastfeeding on dis-
charge.12 Using these data, these authors argued that the
introduction of DHM may serve to extend a culture of breast-
feeding. Similarly, others have argued that DHM should be
considered a supportive measure to mothers expressing milk
for their preterm infants and have used it as part of package
of measures to try to increase maternal breastfeeding rates13
and promote a culture of using only human milk14 on NICUs.
However, anecdotally, concerns have been raised that the
introduction of DHM to a NICU may in fact discourage
maternal breastfeeding.13,14 In addition, the authors of one
study have shown that promoting DHM can lead to an unin-
tended decrease in the use of OMM, perhaps by providing an
“acceptable alternative” to the initiation and maintenance of
lactation.15 There is thus uncertainty as to whether the further
introduction of DHM will affect either positively or nega-
tively on maternal breastfeeding rates in NICUs.
Two large trials in North America are currently addressing
whether there are clinical benefits to infants of using DHM
compared with formula.16,17 However, because these trials are
both blinded, impacts on health professional or maternal behav-
iors will not be fully determined. Thus, the aim of this review
was to strengthen the evidence base for the use of DHM and to
determine the effects of DHM provision on measures of OMM
use during admission and on breastfeeding rates at discharge.
We addressed the following research question: in mothers with
an infant admitted to a neonatal unit (population), what are the
effects of using DHM (intervention) versus formula milk (com-
parison) on maternal breastfeeding rates in, and on discharge
from, the NICU (outcome)? Given the complexity of DHM as
an intervention, we anticipated there might be relatively few
randomized controlled trials and that cluster trials and/or obser-
vational studies would require research synthesis.
This review and the manuscript reporting it was prepared
according to the PRISMA guidelines,18 and the completed
PRISMA checklist is available in Supplementary Appendix
S1, available online. We carried out a systematic literature
review in October 2014 using the following databases:
Medline,19 Embase,20 and Global Health21 (all using the OVID
interface)22; The Cochrane Library23; CINAHL24; Global
Health Library25; and Current Controlled Trials.26 Search
terms were generated using MeSH and Emtree terms relating
to breast milk, infant formula, milk banks, milk donation, and
neonatal units, with input from a medical librarian. A complete
list of search terms, formatted for each database, is available
within the study protocol in Supplementary Appendix S2. The
review is registered on PROSPERO27 (CRD42014013162).
Databases were searched from 1946 onward. Only studies
with abstracts published in the Latin alphabet were reviewed,
and these were translated if necessary by one of the authors
(T.W.). We conducted reference searches of the studies that
met the inclusion criteria, carried out citation tracking of
these studies via Google Scholar,28 and contacted experts in
the field in North America, Europe, and Australia to identify
further relevant studies. Two reviewers (T.W. and J.S.) inde-
pendently assessed the articles identified in the screening
search using the inclusion and exclusion criteria.
Inclusion/Exclusion Criteria
Studies were included if (1) the study was original research,
(2) the study was a controlled trial with participants allocated
randomly or an observational trial examining the impact on
maternal OMM provision or breastfeeding rates pre- and pos-
tintroduction of DHM to a neonatal unit, (3) the study popula-
tion was infants admitted to a neonatal unit, (4) the study
specifically compared enteral feeding with DHM versus for-
mula, and (5) the study provided quantitative data on maternal
breastfeeding rates during the admission or on discharge.
Studies were excluded if the patient population included
infants in postnatal or pediatric wards or did not compare
donor breast milk directly with formula. Study types that
were excluded were (1) case reports or opinion pieces with-
out primary data or (2) qualitative studies that did not pro-
vide data on the proportion of mothers’ breastfeeding during
the admission or on discharge.
Data Extraction, Assessment of Study Quality,
and Risk of Bias
The following data were extracted from the studies meeting
the inclusion criteria: authors, study setting and country
where it took place, research question/study aims, definition
of patient population, outcome measure, study sample size,
rates of breast milk use prior to introduction of donor milk to
a unit, and rates of breast milk use after the introduction of
donor milk. Where data were given for breastfeeding rates on
discharge, it was noted where this was on discharge from and
the definition of the time period used (eg, within 48 hours of
discharge). Data were entered onto Microsoft Excel
(Microsoft Corporation, Redmond, WA, USA).
To assess the risk of bias within each individual study, we
applied principles from the Cochrane Collaboration and the
Working Group for Grading of Recommendations Assessment,
Development and Evaluation.29 Modifying a scoring system
used previously by one of us,30 we assessed the quality of each
study as being high, moderate, or low, according to study
design, sample size, quality of the control group, calculation of
an odds ratio/relative risk, confounding factors, and the geo-
graphical spread of studies. Details of the scoring system can
be found in Supplementary Appendix S3.
To assess the risk of bias across studies, we noted
whether or not each study had been published in a peer-
reviewed journal. We contacted the principal authors of
Williams et al 3
each included study to ascertain if they could share any
unpublished data that might influence the cumulative evi-
dence available. Finally, we contacted experts in the field to
ensure there were no large data sets that were unavailable
due to publication bias.
Data Analysis
Where data for breastfeeding rates after the introduction of
DHM were directly comparable between studies, the num-
bers of infants in each group were aggregated and a relative
risk (RR) with a 95% confidence interval (CI) was calcu-
lated.31 The exposure for these calculations was the intro-
duction of DHM to a neonatal unit. Where data were not
comparable between studies, the outcomes before and after
the introduction of DHM were extracted, and it was noted
whether a summary measure had been calculated.
Our database search yielded 374 records, and consultation
with experts in the field identified 4 further studies. Citation
tracking of studies that met the inclusion criteria yielded 25
additional records, and after excluding duplicates, a total of
286 studies were screened. Fourteen of these studies were
selected for full-text review, of which 10 studies met the
inclusion criteria (Figure 1). Of the remaining 4, 1 was
excluded as it duplicated data from an included study,32 1
was not based in a neonatal unit,33 1 did not compare breast-
feeding rates before and after the introduction of DHM,34
and 1 provided no quantitative data on breastfeeding rates.35
Six of the included studies were based in the United
States,13,14,36-38 2 in Spain,39,40 and 1 study in the United
Kingdom41 and Australia.42 All the studies were published
since 2008 but included data on infants born between 2001
and 2014. Table 1 provides a summary of the study
Quality Assessment and Risk of Bias
The assessment of study quality is shown in Table 2. One of
the studies was judged to be of high quality,39 7[AQ: 4] of
the studies were assessed to be of moderate quality,14,36-38,41
and the remaining 213,42 to be of low quality. Only 1 study
was prospective and interventional,14 and only 2 included
more than one hospital site.13 Two studies included DHM as
part of a bundle of measures designed to increase maternal
breastfeeding rates.13,14 Six were published in peer-reviewed
journals,13,14,36,37,40 and 4 were conference abstracts.38,41,42
None of the contacted authors of the included studies shared
unpublished data to contribute to our analysis. Consultation
with experts in the field did not reveal any large unpublished
data series relevant to this review.
There was substantial heterogeneity in the definition of the
patient population in the included studies. One study looked
at infants born at < 30 weeks’ gestation,42 2 studies examined
infants born at < 32 weeks’ gestation or with a birth weight
(BW) of < 1.5 kg,13,40 5 studies used a BW < 1.5 kg as the
inclusion criteria,36-38,41,43 1 study used BW < 2 kg,14 and 1
study used BW < 1 kg.39 Outcome definitions were similarly
heterogeneous and were comparable in 4 studies for any
breastfeeding on discharge14,39,40,43 and in 2 studies for exclu-
sive breastfeeding on discharge40,42 and exclusive adminis-
tration of OMM days 1 to 28.37,40 Only 1 study40 defined a
time period before discharge for the receipt of breast milk
(48 hours), and none of the studies defined how that breast
milk was given on discharge. Five[AQ: 5] studies did not
document whether all infants or only surviving infants were
used as the denominator for measures of maternal breast-
feeding,13,14,36,38,42,43 3 excluded infants who died from their
analysis,37,40,41 and 1 study included these in the denomina-
tor.39 When performing calculations, the denominators used
were those given by the authors, and no adjustments were
made for the infants who died, as these numbers were small.
Studies also varied in how DHM had been introduced to a
neonatal unit. Three studies looked at changes in the admin-
istration of OMM after the introduction of a milk bank to a
neonatal unit.40-42 Two studies examined whether there was a
change in practice after the introduction of DHM as part of a
bundle aimed to increase the use of human milk.13,14 One
examined changes in practice after a new policy specifying
use of DHM when not enough OMM was available,37 and the
remaining 4 examined changes in practice after the introduc-
tion of DHM to a neonatal unit.36,38,39,43
Effects of Introduction of DHM on Maternal
Breastfeeding Rates
Two studies40,42 examined the effect of the introduction of
DHM on exclusive maternal breastfeeding rates on dis-
charge. One of these provided no definition of “exclusive
breastfeeding” on discharge, and the studies included 2 dif-
ferent patient population groups (born at < 30 weeks42 vs
born at < 32 weeks or BW < 1.5 kg).40 Aggregating the data
showed no significant difference between the 2 groups, with
an RR of 1.12 (95% CI, 0.91-1.40; P = .27) of breastfeeding
on discharge after the introduction of DHM.
Four studies14,39,40,43 provided data on infants receiving
any breastfeeding on discharge after the introduction of
DHM. In one of these studies,14 DHM was introduced as part
of a program aimed to increase the volume of human milk
given to infants born at less than 2 kg. No significant differ-
ence (P = .09) was found in infants receiving any breast
feeds on discharge after the introduction of the program. No
formal definition was given of “any breastfeeding on dis-
charge” in this study. Another study43 found a significant
4 Journal of Human Lactation
increase (P = .02) in any breastfeeding on discharge after the
introduction of DHM milk to a neonatal unit. Patient popula-
tion groups differed between the 4 study groups (BW < 2
kg,14 < 1.5 kg,43 < 1 kg39 and born at < 32 weeks or BW < 1.5
kg).40 Aggregating the data for the 4 studies, a significant
difference was found between the 2 groups (RR, 1.19; 95%
CI, 1.06-1.35; P = .005), showing an increase in maternal
breastfeeding after the introduction of DHM.
Two studies37,40 examined the effect of the introduction of
DHM on the exclusive administration of OMM in the first 28
days of life. One used a patient population of infants born at <
32 weeks,37 and another looked at infants born at < 32 weeks or
with a BW < 1.5 kg.40 In the second study, there was a reduc-
tion (from 40% to 13%) in the percentage of infants receiving
exclusive OMM. According to the authors, this was because
after the introduction of DHM, it was used when there was not
enough milk from the infants’ own mothers, whereas prior to
the introduction of DHM, infants were fed by parenteral nutri-
tion the first days of their lives to avoid infant formula.
Aggregating the data, no significant difference was found
between the 2 groups (RR, 1.08; 95% CI, 0.78-1.49; P = .65).
All the data above are shown in Supplementary Appendix S4.
Single studies provided data on a number of variables
related to the use of OMM after the introduction of DHM
Figure 1. PRISMA Flowchart.
Abbreviations: BF, breastfeeding; DEBM, donor-expressed breast milk.
Table 1. Summary of Study Characteristics.
(Country) Research Question/Study Aims
of Patient
Population Outcome
Size Main Findings
Beasmore et al41 NICU
Did the introduction of an HMB change OMM and
formula milk usage during the establishment of
enteral feeding?
BW < 1.5 kg % Exclusive OMM until
full enteral feeds
122 65% pre vs 70% post,
P = .51
Bishop et al36 NICU
To assess the influence of DHM on the incidence of
NEC and the amount of OMM use
BW < 1.5 kg % of feeds that contained
> 50% OMM up to 34
weeks CGA
331 51% pre vs 54% post,
P = .95
Delfosse et al13 Level 4 NICU
To determine acceptance of DHM for feeding
preterm infants and whether offering DHM alters
OMM feeding
Born at <
32 weeks
or BW <
1.5 kg
% OMM given (volume)
days 1 to 14 of life
650 63% at start of
intervention vs 60% at
end of intervention,
no P value calculated
et al15
Level 4 NICU
To evaluate the impact of a DHM program on OMM
and formula feedings
BW < 1.5 kg % Feeds that were OMM
days 1 to 14 of life
265 85% pre vs 68% post,
P < .01
% Feeds that were OMM
days 1 to 28 of life
265 71% pre vs 61% post,
P = .04
Kok et al42 Neonatal unit
The effects of the introduction of an HMB on the
feeding of preterm infants on discharge
Born at < 30
Exclusive BF on discharge
from neonatal unit (not
specified further)
155 53% pre vs 64% post,
no P value calculated
Marinelli et al37 Level 4 NICU
To compare enteral intake type in preterm infants
before vs after establishing a DHM policy
BW < 1.5 kg % OMM given (volume)
days 1 to 28
154 66% pre vs 70% post,
no P value calculated
Exclusive administration
of OMM days 1 to 28
154 38% pre vs 55% post,
no P value calculated
Montgomery et al14 Level 3 NICU
To assess the effects of a program designed to
improve human milk availability for preterm infants
on breast milk use and feeding-related outcomes
BW < 2 kg Receiving any BF on
discharge home (not
specified further)
245 44% pre vs 53% post,
P = .09
Parker et al43 Level 3 NICU
To determine whether rates of consumption of
OMM at discharge home changed in the 2 years
pre- and postimplementation of a DHM program
BW < 1.5 kg Any BF on discharge
from hospital (not
specified further)
154 43% pre vs. 65% post,
P = .02
Utrera Torres
et al40
Neonatal unit
To assess the impact that opening an HMB had on
the proportion of infants breastfeeding at discharge
and other practices related to feeding
Born at <
32 weeks
or BW <
1.5 kg
Exclusive BF on discharge
from hospital (within 48
hours of discharge)
104 54% pre vs 56% post,
P = .87
Any BF on discharge
from hospital (within 48
hours of discharge)
104 86% pre vs 78% post,
P = .27
Exclusive administration
of OMM days 1 to 28
104 40% pre vs 13% post,
no P value calculated
Verd et al39 NICUs
To assess the impact of an exclusive human milk diet
to nourish extremely low birth weight infants in
the NICU
BW < 1.5 kg Any BF on discharge
from hospital (not
specified further)
201 67% pre vs 70% post,
P = .74
Abbreviations: BF, breastfeeding; BW, birth weight; CGA, corrected gestational age; DHM, donor human milk; HMB, human milk bank; NEC, necrotizing enterocolitis; NICU, neonatal intensive care unit;
OMM, own mother’s milk.
Table 2. Quality Assessment.
Study Design
Size (Score)
Quality of Control Group
Calculation of
OR/RR (Score)
Factors (Score)
Spread (Score)
Score (Quality
of Study)
Beasmore et al41 Retrospective
observational (0)
122 (1) Demographic variables noted, no
differences (2)
Yes (2) None (2) Data from 1 unit
7 (moderate)
Bishop et al36 Retrospective
observational (0)
331 (1) Demographic variables noted, no
differences (2)
Yes (2) None (2) Data from 1 unit
7 (moderate)
Delfosse et al13 Retrospective
observational (0)
650 (2) No control group (0) No (0) DHM introduced as
part of bundle (1)
Data from 2
units (1)
4 (low)
et al15
observational (0)
265 (1) Demographic variables noted, no
differences (2)
Yes (2) No data (0) Data from 1 unit
5 (moderate)
Kok et al42 Retrospective
observational (0)
155 (1) No demographic variables
documented (0)
No (0) No data (0) Data from 1 unit
1 (low)
Marinelli et al37 Prospective
cohort study (1)
154 (1) Demographic variables noted,
significant differences (1)
Yes (2) None (2) Data from 1 unit
7 (moderate)
et al14
interventional (2)
245 (1) Demographic variables noted,
significant differences (1)
Yes (2) DHM introduced as
part of bundle (1)
Data from 1 unit
7 (moderate)
Parker et al43 Retrospective
observational (0)
154 (1) Demographic variables noted, no
comment on whether significant
differences between groups (0)
Yes (2) None (2) Data from 1 unit
5 (moderate)
Utrera Torres
et al40
observational (0)
122 (1) Demographic variables
documented, significant
differences (1)
Yes (2) None (2) Data from 1 unit
6 (moderate)
Verd et al39 Retrospective
observational (0)
201 (1) Demographic variables
documented, no differences (2)
Yes (2) None (2) Data from 4
units (2)
9 (high)
Abbreviations: DHM, donor human milk; OR, odds ratio; RR, relative risk.
Williams et al 7
(Table 1). A single-center study judged to be of moderate
quality found that the introduction of DHM was associated
with a significant decrease in the percentage of feeds that
were OMM days 1 to 14 (P < .01) and days 1 to 28 (P = .04)
of life.38 One study examined the percentage of exclusive
OMM given until full feeds were established41 and found no
significant difference (P = .51) between the pre- and post-
DHM groups. One study examined the percentage of feeds
that contained > 50% OMM given to infants of up to 34
weeks corrected gestational age36 and again found no differ-
ence between the groups (P = .95). Two studies looked at the
percentage of OMM given (as volume) for days 1 to 14 13
and 1 to 28 of life,37 respectively, but did not calculate a sta-
tistical summary measure.
Interest in the use of DHM has increased over the past
decade, manifest by a worldwide expansion in the number of
HMBs. Despite this, there remains a relative lack of high-
quality research into the impact of DHM on the recipient
neonatal population or its wider societal effects. Our system-
atic review of the use of DHM on maternal breastfeeding
rates confirmed this lack of high-quality data, identifying
only 10 studies that met the inclusion criteria. These studies
were geographically limited, available from only 4 countries,
and most of the included studies (6/10) were from the United
States. Four of the 10 included studies were conference
abstracts and were therefore not peer reviewed. Using a scor-
ing system to assess study quality, only 1 was judged to be of
high quality.
The available data demonstrate mixed effects on mea-
sures of maternal breastfeeding when DHM is introduced to
a neonatal unit. Relative risk calculations with aggregated
data from 4 studies did show a significant increase in any
breastfeeding on discharge after the introduction of DHM.
However, there appeared to be no effect on exclusive breast-
feeding on discharge or the exclusive administration of
OMM in the first 28 days of life after the introduction of
DHM. Even where DHM was introduced as part of a care
bundle (as it was in 2 of the included studies),13,14 in indi-
vidual centers, there appeared to be no significant increase in
measures of maternal breastfeeding. Conversely, 1 of the 10
studies showed a statistically significant decrease in the use
of OMM after the introduction of DHM.38 This was posited
by the authors to be due to the fact that the provision of DHM
was discouraging mothers from expressing breast milk.
However, the remainder of the available evidence does not
support the hypothesis that the introduction of DHM has an
adverse effect on breastfeeding rates in NICUs.
Some of the heterogeneity in results may reflect the fact
that DHM can be used in a variety of ways. One study
described DHM as a “bridge” to be used until a mother is
able to express enough milk for her preterm infant,13 whereas
others describe the rationale for DHM as being a way to
reduce the volume of formula feeds being given to preterm
infants14 or as a means to more rapidly introduce enteral
feeds.40 Given that DHM is introduced for a variety of rea-
sons and in a variety of ways (as part of package of measures,
by opening an HMB, or by replacing preterm formula in
feeding guidelines), it is perhaps not surprising that no con-
sistent effect is seen on measures of maternal breastfeeding.
Inclusion criteria and definitions of outcomes varied between
the studies, precluding a formalized assessment of a risk of
bias using a funnel plot. Where aggregated relative risks were
calculated, study groups’ patient populations differed in terms
of birth weight and gestation, as well as whether they included
infants who had died in their denominator, although the num-
ber of these was small. Our data samples were small for each
variable, and the calculated intervals were wide, so that small
but important effects in either direction could not be excluded
for exclusive breastfeeding on discharge or use of OMM in the
first 28 days of life. For other outcomes, the heterogeneity of
study variables and patient populations limited the ability to
meta-analyze the data. We are unable to comment on whether
having consistent definitions of patient population and study
outcomes would have supported a positive effect of DHM on
other indicators of maternal breastfeeding success. However,
it is likely that the larger data sets permitted by consistent defi-
nitions would have allowed a more definitive answer to the
question of whether DHM affects these.
Eight of the 10 studies were retrospective, and there was a
high risk of bias, with only 1 study judged to be of high qual-
ity. We attempted to rule out publication bias by contacting
experts in the field to see whether substantial unpublished
databases existed on this topic and could not find evidence for
any. However, it remains possible that reports of trials with
negative findings have not entered peer-reviewed journals or
been accepted for conferences. In addition, we were unable to
obtain unpublished data from the included studies on breast-
feeding rates that may have influenced our results.
While we chose to concentrate on surrogate markers of
how much OMM was provided during admission and on dis-
charge, the introduction of DHM to a neonatal unit may
affect other important outcomes. These include rates of
OMM initiation, the duration of provision of OMM, the total
proportion of human milk (ie, OMM and DHM) given to
infants during their admission, the length of hospital admis-
sion, and practices related to the fortification of human milk.
Thus, the narrow focus of our research question may limit
the applicability of the findings of this systematic review.
In summary, the available data demonstrate positive effects on
some, but not all, measures of maternal breastfeeding rates
when DHM is introduced to a neonatal unit. There is also
8 Journal of Human Lactation
some evidence that in certain settings, rates might actually
decrease. However, overall there is probably sufficient data
available to reassure clinicians that the introduction of DHM
in itself is unlikely to adversely affect breastfeeding rates. If
the introduction of DHM is to be promoted as a cost-effective
way of promoting maternal breastfeeding, further well-
designed studies with standardized populations, consistent use
of DHM, measurable breastfeeding outcomes, and economic
evaluation may help to inform uniformity of practice. Ideally,
these could be integrated into large randomized controlled tri-
als looking at the effects of DHM on clinical variables such as
mortality, NEC, sepsis, and longer term health benefits.
We thank Marshall Dozier, Academic Liaison Librarian at the
University of Edinburgh, for her input into our search strategy. We
also thank Professor Paula Meier, Professor Richard Schanler,
Professor Maria Quigley, Professor Kathleen Marinelli, Professor
Karen Simmer, and an anonymous reviewer for their expert advice
on data (published and unpublished) that might meet the inclusion
criteria for this review.
Declaration of Conflicting Interests
The authors declared the following potential conflicts of interest
with respect to the research, authorship, and/or publication of this
article: Nicholas Embleton chairs a working group for the British
Association of Perinatal Medicin producing a framework for the
use of DHM in the United Kingdom, and Thomas Williams and
Judith Simpson are members of this group. Harish Nair has indi-
cated he has no potential conflicts of interest to disclose.
Funding[AQ: 6]
The authors disclosed receipt of the following financial support for
the research, authorship, and/or publication of this article: Funding
for travel allowing the participants to meet to plan this research was
provided by the British Association of Perinatal Medicine. Nicholas
Embleton declares that he has received research funding from man-
ufacturers of artificial milk formula and spoken at industry-spon-
sored events. The other authors have indicated they have no
financial relationships relevant to this article to disclose.
Supplementary Material
Supplementary material for this article is available online at http://
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... MOM is the best and most optimal nutritional source for preterm infants, and if not available or if it is insufficient then HDM is recommended [21]. In general, the use of pasteurized term HDM is increasing in NICUs and has been associated with higher rates of exclusive human milk feeding at discharge [5,39]. However, several studies have demonstrated that the macronutrients, particularly the protein levels, were significantly lower in pooled term HDM compared to MOM [5,22,23]. ...
... Single preterm HDM is an alternative source of preterm infants' nutrition and contains higher concentrations of protein than pooled term HDM [23,42]. Consequently, single preterm HDM might be an valuable alternative to pooled term HDM for preterm infant nutrition to support adequate growth and body composition [39]. In a previous study, we stated that the use of single preterm HDM is feasible and has a positive effect on the time to full enteral feeding, ROP, and culture-proven sepsis in comparison to infants fed with preterm formula [44]. ...
Full-text available
(1) If mother´s own milk (MOM) is not available, pooled term human donor milk (HDM) is commonly used. Compared to MOM, term HDM contains less protein and fat and is associated with impaired growth. HDM from mothers of preterm infants is an alternative source and contains higher protein levels compared to term HDM, but the impacts on growth and body composition are unclear. (2) Methods: Infants born below 32 weeks of gestation and below 1500 g between 2017–2022, who underwent air displacement plethysmography (Pea Pod®) to determine body composition (FFM: fat-free mass; FM: fat mass) at term-equivalent age, were included. A comparison between infants fed with MOM > 50% (MOM-group) and single preterm HDM > 50% (HDM-group) was conducted. (3) Results: In total, 351 infants (MOM-group: n = 206; HDM-group: n = 145) were included for the analysis. The median FFM-Z-score (MOM-group: −1.09; IQR: −2.02, 1.11; HDM-group: −1.13; IQR: −2.03, 1.12; p = 0.96), FM-Z-score (MOM-group: 1.06; IQR: −0.08, 2.22; HDM-group: 1.19; IQR: −0.14, 2.20; p = 0.09), and median growth velocity (MOM-group: 23.1 g/kg/d; IQR: 20.7, 26.0; HDM: 22.5 g/kg/d; IQR: 19.7, 25.8; p = 0.15) values were not significantly different between the groups. (4) Conclusion: Single preterm HDM is a good alternative to support normal growth and body composition.
... [2][3][4] It is estimated that over 800,000 infants worldwide receive DHM annually, and multiple studies underscore short-and long-term benefits of DHM over bovine-origin preterm formula (PTF). [14][15][16] DHM composition and properties are subject to the complexity of processing involving storage, freezing, pasteurization, thawing, and homogenization, resulting in quantitative and qualitative attenuation of bioactive proteins and immunomodulatory components. [17][18][19][20] In this context, it is reasonable to suggest that even when fortifiers are added to freshly expressed mother's own milk (FreMOM), frozen mother's own milk (FroMOM), preterm donor human milk (PTDHM), and full-term donor human milk (FTDHM), all of which are variably used during the course of the NICU stay of VPT and VLBW infants; significant nutritional, biochemical, immunological, and microbiological variations exist potentially influencing the clinical outcomes. ...
Full-text available
Background Human milk (HM) fortification has been recommended for the nutritional optimization of very low–birthweight infants. This study analyzed the bioactive components of HM and evaluated fortification choices that could accentuate or attenuate the concentration of such components, with special reference to human milk-derived fortifier (HMDF) offered to extremely premature infants as an exclusive human milk diet. Materials and Methods An observational feasibility study analyzed the biochemical and immunochemical characteristics of mothers' own milk (MOM), both fresh and frozen, and pasteurized banked donor human milk (DHM), each supplemented with either HMDF or cow's milk-derived fortifier (CMDF). Gestation-specific specimens were analyzed for macronutrients, pH, total solids, antioxidant activity (AA), α-lactalbumin, lactoferrin, lysozyme, and α- and β-caseins. Data were analyzed for variance applying general linear model and Tukey's test for pairwise comparison. Results DHM exhibited significantly lower (p < 0.05) lactoferrin and α-lactalbumin concentrations than fresh and frozen MOM. HMDF reinstated lactoferrin and α-lactalbumin and exhibited higher protein, fat, and total solids (p < 0.05) in comparison to unfortified and CMDF-supplemented specimens. HMDF had the highest (p < 0.05) AA, suggesting the potential capability of HMDF to enhance oxidative scavenging. Conclusion DHM, compared with MOM, has reduced bioactive properties, and CMDF conferred the least additional bioactive components. Reinstatement and further enhancement of bioactivity, which has been attenuated through pasteurization of DHM, is demonstrated through HMDF supplementation. Freshly expressed MOM fortified with HMDF and given early, enterally, and exclusively (3E) appears an optimal nutritional choice for extremely premature infants.
... Breastfeeding at discharge. Williams et al, 58 in their review of 10 nonrandomized studies, concluded that having access to DHM resulted in a 19% increase in exclusive breastfeeding at discharge compared with the centers without access to DHM. This higher incidence of exclusive breastfeeding at discharge (although it did not reach a statistical significance in the meta-analysis) was in line with the Italian data published by Arslanoglu et al 59 and US data published by Kantorowska et al. 60 In both studies, the presence of an HMB on site or having access to an HMB had a remarkably positive impact for NICUs on the exclusive breastfeeding rates at discharge (Italian data: 60.4% vs 52.8%, P < 0.04; US data: 10% increase in breast milk feeding at NICU discharge). ...
Full-text available
In Europe, an increasing number of human milk banks (HMBs) collect donor human milk to feed preterm infants when their mother's milk is not available or not enough. Moreover, donor milk is a bridge to breastfeeding, with positive clinical and psychological advantages for both mother and infant. Italy, with 41 HMBs actively operating in 2022, has the highest number of HMBs in Europe. The process of human milk donation is complex, so activity of HMBs must be regulated according to well-established rules. The present recommendations have been prepared as a tool to standardize the organization, management, and procedures of HMBs operating in Italy and to determine the minimal essential requirements to establish new HMBs. This article covers all the aspects of human milk donation and human milk banking, including general recommendations, donor recruitment and screening, expression, handling and storage of donor human milk, milk screening, and milk treatment (pasteurization). A pragmatic approach was taken to drafting the recommendations. Items for which there was consensus or robust published evidence on which to base recommendations were included. When there were differences that could not be resolved by reference to published research, a statement of explanation based on the expert opinion of the authors (all members of the Italian Association of Human Milk Banks) was included. Implementation of these recommendations can contribute to promotion of breastfeeding.
... 22 A systematic review showed that DHM may have a positive effect on any breast feeding, but rates of exclusive breast feeding on discharge are unchanged. 23 A large observational study in 56 NICUs in the USA showed increased rates of breast feeding in NICUs where a DHM programme was implemented, along with a decrease in NEC rate. 24 In contrast, another single-centre retrospective study showed that MOM provision decreased following the implementation of a donor milk programme, and preterm infants consumed less MOM in the first 14 days in the post-DHM cohort. ...
Full-text available
Introduction Mother’s own breast milk (MOM) is the optimal nutrition for preterm infants as it reduces the incidence of key neonatal morbidities and improves long-term outcomes. However, MOM shortfall is common and either preterm formula or pasteurised donor human milk (DHM) may be used, although practice varies widely. Limited data suggest that the use of DHM may impact maternal beliefs and behaviours and therefore breastfeeding rates. The aim of this pilot study is to determine if longer duration of DHM exposure increases breastfeeding rates, and if a randomised controlled trial (RCT) design is feasible. Methods and analysis The Human Milk, Nutrition, Growth, and Breastfeeding Rates at Discharge (HUMMINGBIRD) Study is a feasibility and pilot, non-blinded RCT with a contemporaneous qualitative evaluation. Babies born less than 33 weeks’ gestation or with birth weight <1500 g whose mothers intend to provide MOM are randomly assigned to either control (DHM used to make up shortfall until full feeds and preterm formula thereafter) or intervention (DHM used for shortfall until 36 weeks’ corrected age or discharge if sooner). The primary outcome is breast feeding at discharge. Secondary outcomes include growth, neonatal morbidities, length of stay, breastfeeding self-efficacy and postnatal depression using validated questionnaires. Qualitative interviews using a topic guide will explore perceptions around use of DHM and analysed using thematic analysis. Ethics approval and dissemination Nottingham 2 Research Ethics Committee granted approval (IRAS Project ID 281071) and recruitment commenced on 7 June 2021. Results will be disseminated in peer-reviewed journals. Trial registration number ISRCTN57339063 .
Ines Salmoral and Denise McGuinness reflect on whether human donor milk should be made available for healthy term infants in the maternity setting
Human milk (HM) is a highly evolutionary selected, complex biofluid, which provides tailored nutrition, immune system support and developmental cues that are unique to each maternal–infant dyad. In the absence of maternal milk, the World Health Organisation recommends vulnerable infants should be fed with screened donor HM (DHM) from a HM bank (HMB) ideally embedded in local or regional lactation support services. However, demand for HM products has arisen from an increasing awareness of the developmental and health impacts of the early introduction of formula and a lack of prioritisation into government‐funded and nonprofit milk banking and innovation. This survey of global nonprofit milk bank leaders aimed to outline the trends, commonalities and differences between nonprofit and for‐profit HM banking, examine strategies regarding the marketing and placement of products to hospital and public customers and outline the key social, ethical and human rights concerns. The survey captured information from 59 milk bank leaders in 30 countries from every populated continent. In total, five companies are currently trading HM products with several early‐stage private milk companies (PMCs). Products tended to be more expensive from PMC than HMB, milk providers were financially remunerated and lactation support for milk providers and recipients was not a core function of PMCs. Current regulatory frameworks for HM vary widely, with the majority of countries lacking any framework, and most others placing HM within food legislation, which does not include the support and care of milk donors and recipient prioritisation. Regulation as a Medical Product of Human Origin was only in place to prevent the sale of HM in four countries; export and import of HM was banned in two countries. This paper discusses the safety and ethical concerns raised by the commodification of HM and the opportunities policymakers have globally and country‐level to limit the potential for exploitation and the undermining of breastfeeding.
The use of donor human milk (DHM) where there is a shortfall of maternal milk can benefit both infant and maternal outcomes but DHM supply is not always assured. This study aimed to understand current DHM usage in UK neonatal units and potential future demand to inform service planning. An online survey was disseminated to all UK neonatal units using Smart Survey or by telephone between February and April 2022 after development alongside neonatal unit teams. Surveys were completed by 55.4% of units (108/195) from all 13 Operational Delivery Networks. Only four units reported not using DHM, and another two units only if infants are transferred on DHM feeds. There was marked diversity in DHM implementation and usage and unit protocols varied greatly. Five of six units with their own milk bank had needed to source milk from an external milk bank in the last year. Ninety units (84.9%) considered DHM was sometimes (n = 35) or always (n = 55) supportive of maternal breastfeeding, and three units (2.9%) responded that DHM was rarely supportive of breastfeeding. Usage was predicted to increase by 37 units (34.9%), and this drive was principally a result of parental preference, clinical trials and improved evidence. These findings support the assumption that UK hospital DHM demand will increase after updated recommendations from the World Health Organization (WHO) and the British Association of Perinatal Medicine. These data will assist service delivery planning, underpinned by an ongoing programme of implementation science and training development, to ensure future equity of access to DHM nationally.
Purpose: The purpose of this study is to examine perceptions and experiences of women who donate human milk and highlight various aspects of the breast milk donation process. Study design: A cross-sectional descriptive study. Methods: An online survey was conducted with a convenience sample of women who donated milk at several milk banks in the United States. A questionnaire of 36 closed and open-ended items were developed and validated by the research team. Descriptive statistics and content analysis were used. Semantic content analysis involved three procedures: coding, categorizing text units, and refining the identified themes. Results: A total of 236 women who donated breast milk completed the questionnaire. Mean age of participants was 32.7±4.27 and 89.40% were non-Hispanic White women with a bachelor's degree (32.20%) or graduate degree (54.70%). Most participants were women who actively donated breast milk, ranging from one to four times. Two themes, facilitators and barriers of milk donation, were identified. Facilitators to milk donation included attitudes toward milk donation, commitment for donating, motivation in donating, and support. Barriers included personal factors, environment, milk donor process, and psychosocial factors. Clinical implications: Nurses, health care providers, and lactation professionals should educate women about milk donation resources and opportunities. Strategies to increase awareness about milk donation among underrepresented groups such as women of color are highly recommended. Future research is needed to further explore specific factors that increase milk donation awareness and minimize barriers to potential donors.
Multicomponent fortification is the standard of care to support short-term growth in preterm infants receiving human milk. There is no consensus regarding the optimal timing, method, or products used to fortify human milk. Both bovine milk-based and human milk-based human milk fortifiers are safe options, though increased fortification and enrichment may be needed to achieve adequate growth. Additional studies are needed to evaluate newer fortifier products and fortification strategies.
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This study evaluated the impact of an exclusive human milk diet to nourish extremely low birth weight infants in the neonatal intensive care unit. This multicenter pre-post retrospective study included all inborn infants <1,000 g admitted to four Level IV neonatal intensive care units either before or after implementing a donor human milk policy. The feeding protocol was unchanged in both periods. Collected data included maternal/infant demographics, infant clinical data, and enteral intake as mother's own milk, donor milk, and formula. Two hundred one infants were enrolled. Infant growth and other clinical outcomes were similar in both groups. Exposure to mother's own milk at discharge was not different. Median time in oxygen and duration of mechanical ventilation were significantly higher among formula-fed infants (63 versus 192 hours [p=0.046] and 24 versus 60 hours [p=0.016], respectively). Our results add evidence supporting the safety of donor milk. This study also found an association between exposure to formula in preterm infants and the requirement for respiratory support, a finding that warrants further investigation.
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Understanding the causes and timing of death in extremely premature infants may guide research efforts and inform the counseling of families. We analyzed prospectively collected data on 6075 deaths among 22,248 live births, with gestational ages of 22 0/7 to 28 6/7 weeks, among infants born in study hospitals within the National Institute of Child Health and Human Development Neonatal Research Network. We compared overall and cause-specific in-hospital mortality across three periods from 2000 through 2011, with adjustment for baseline differences. The number of deaths per 1000 live births was 275 (95% confidence interval [CI], 264 to 285) from 2000 through 2003 and 285 (95% CI, 275 to 295) from 2004 through 2007; the number decreased to 258 (95% CI, 248 to 268) in the 2008-2011 period (P=0.003 for the comparison across three periods). There were fewer pulmonary-related deaths attributed to the respiratory distress syndrome and bronchopulmonary dysplasia in 2008-2011 than in 2000-2003 and 2004-2007 (68 [95% CI, 63 to 74] vs. 83 [95% CI, 77 to 90] and 84 [95% CI, 78 to 90] per 1000 live births, respectively; P=0.002). Similarly, in 2008-2011, as compared with 2000-2003, there were decreases in deaths attributed to immaturity (P=0.05) and deaths complicated by infection (P=0.04) or central nervous system injury (P<0.001); however, there were increases in deaths attributed to necrotizing enterocolitis (30 [95% CI, 27 to 34] vs. 23 [95% CI, 20 to 27], P=0.03). Overall, 40.4% of deaths occurred within 12 hours after birth, and 17.3% occurred after 28 days. We found that from 2000 through 2011, overall mortality declined among extremely premature infants. Deaths related to pulmonary causes, immaturity, infection, and central nervous system injury decreased, while necrotizing enterocolitis-related deaths increased. (Funded by the National Institutes of Health.).
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Background: Use of donor human milk (DHM) is increasing, but criteria for its use are not well defined. Materials and methods: We conducted a 34-question Internet-based survey of medical directors of U.S. level 3 and level 4 neonatal intensive care units (NICUs), with the goal of describing specifics of policies developed to guide DHM use in U.S. NICUs. Respondents reported NICU characteristics and details of policies concerning DHM use. Policy-specified criteria for DHM use, if any, were described. Bivariate and multivariate analyses were used to identify NICU characteristics associated with DHM use. Results: Respondents returned 153 (33%) surveys, with use of DHM reported by 91 (59%). Donor human milk use was more likely with more than 100 annual admissions <1500 g at birth (odds ratio [OR], 2.2; 95% confidence interval [CI], 1.1-4.7) and with Vermont-Oxford Network participants (OR, 4.6; 95% CI, 1.8-11.6). Among 72 NICUs reporting a written policy, criteria for providing DHM required birth weights varying from <1000 to <1800 g and/or gestational ages from <28 to <34 completed weeks, but criteria were reportedly waived in many circumstances. Policies regarding duration of DHM therapy were similarly varied. Conclusions: Criteria for initiating and continuing DHM vary widely among U.S. level 3 and level 4 NICUs. Donor human milk use is more frequent in NICUs with many very low-birth-weight admissions and among Vermont-Oxford Network participants. Further research is needed to define short- and long-term outcomes and cost benefits of DHM use in subgroups of NICU patients, particularly for uses other than necrotizing enterocolitis prevention.
Conference Paper
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Background: Over the past decade, the use of donor human milk (DHM) feedings for very low birthweight (VLBW; <1500 g) infants cared for in the neonatal intensive care unit (NICU) has increased. However, little published research has addressed the mother's decision-making processes with respect to providing consent for DHM feedings. Objective: The purpose of this study was to explore the decision-making processes used by mothers of VLBW infants in the provision of consent for DHM feedings. Methods: Twenty mothers who consented to the use of DHM feedings and whose VLBW infants were hospitalized in a 57-bed Level III NICU in an urban university medical center in the US served as subjects. A qualitative grounded theory methodology that sought to explore the mothers' perceptions and decision-making processes with respect to providing DHM consent was used. One-time, in-depth interviews were conducted an average of 4 (range= 1-11) weeks post-birth, and these data were coded and analyzed using open and axial coding. Results: The sample was predominantly African American (65%), multiparous (60%), <30 years old (60%), low-income (55%), educated beyond high school (80%), and unemployed (55%). Although only 65% (n= 13) had intended to provide their own milk prior to giving birth, 90% (n=18) of the mothers had initiated lactation and provided some milk before the interview. At the time of the interview, 17 of the 20 infants had received DHM. Of the 20 mothers, 12 (60%) immediately provided consent, and 8 (40%) were initially resistant. Reasons for immediately consenting included: having an inadequate milk supply, wanting DHM “just in case” the mother's own milk supply decreased, being unable to transport milk to the NICU on a regular basis, and being unwilling to provide her own milk. Reasons for initial resistance included concerns about the quality of DHM, confidence about the adequacy of her own milk supply, a desire to be the only milk provider, and religious constraints. When approached to provide consent for DHM feedings mothers used either a decisive or a modifiable decision-making process. A decisive consent was made without hesitation and was always in favor of DHM. In contrast, a modifiable consent involved the mothers' decision-making process shifting among resistance, negotiation, and compromise. Resistance was characterized by the mothers' initial reluctance or refusal to consent to DHM feedings, exemplified by mothers with the following comment, “It’s somebody else’s milk.” During negotiation and compromise, the mother willingly or warily accepted the use of DHM. Conclusions: To our knowledge this is the first research to explore the decision-making process used by mothers of VLBW infants when asked to provide consent for DHM feedings. "It's somebody else's milk" characterizes mothers' initial reluctance to DHM, and varies from addressable concerns about the safety and quality of DHM to those that involve maternal self-adequacy and belief systems.
Background: When sufficient maternal breast milk is not available, alternative forms of enteral nutrition for preterm or low birth weight (LBW) infants are donor breast milk or artificial formula. Donor breast milk may retain some of the non-nutritive benefits of maternal breast milk for preterm or LBW infants. However, feeding with artificial formula may ensure more consistent delivery of greater amounts of nutrients. Uncertainty exists about the balance of risks and benefits of feeding formula versus donor breast milk for preterm or LBW infants. Objectives: To determine the effect of feeding with formula compared with donor breast milk on growth and development in preterm or low birth weight (LBW) infants. Search methods: We used the Cochrane Neonatal search strategy, including electronic searches of the Cochrane Central Register of Controlled Trials (CENTRAL; 2019, Issue 5), Ovid MEDLINE, Embase, and the Cumulative Index to Nursing and Allied Health Literature (3 May 2019), as well as conference proceedings, previous reviews, and clinical trials. Selection criteria: Randomised or quasi-randomised controlled trials (RCTs) comparing feeding with formula versus donor breast milk in preterm or LBW infants. Data collection and analysis: Two review authors assessed trial eligibility and risk of bias and extracted data independently. We analysed treatment effects as described in the individual trials and reported risk ratios (RRs) and risk differences (RDs) for dichotomous data, and mean differences (MDs) for continuous data, with respective 95% confidence intervals (CIs). We used a fixed-effect model in meta-analyses and explored potential causes of heterogeneity in subgroup analyses. We assessed the certainty of evidence for the main comparison at the outcome level using GRADE methods. Main results: Twelve trials with a total of 1879 infants fulfilled the inclusion criteria. Four trials compared standard term formula versus donor breast milk and eight compared nutrient-enriched preterm formula versus donor breast milk. Only the five most recent trials used nutrient-fortified donor breast milk. The trials contain various weaknesses in methodological quality, specifically concerns about allocation concealment in four trials and lack of blinding in most of the trials. Most of the included trials were funded by companies that made the study formula.Formula-fed infants had higher in-hospital rates of weight gain (mean difference (MD) 2.51, 95% confidence interval (CI) 1.93 to 3.08 g/kg/day), linear growth (MD 1.21, 95% CI 0.77 to 1.65 mm/week) and head growth (MD 0.85, 95% CI 0.47 to 1.23 mm/week). These meta-analyses contained high levels of heterogeneity. We did not find evidence of an effect on long-term growth or neurodevelopment. Formula feeding increased the risk of necrotising enterocolitis (typical risk ratio (RR) 1.87, 95% CI 1.23 to 2.85; risk difference (RD) 0.03, 95% CI 0.01 to 0.05; number needed to treat for an additional harmful outcome (NNTH) 33, 95% CI 20 to 100; 9 studies, 1675 infants).The GRADE certainty of evidence was moderate for rates of weight gain, linear growth, and head growth (downgraded for high levels of heterogeneity) and was moderate for neurodevelopmental disability, all-cause mortality, and necrotising enterocolitis (downgraded for imprecision). Authors' conclusions: In preterm and LBW infants, moderate-certainty evidence indicates that feeding with formula compared with donor breast milk, either as a supplement to maternal expressed breast milk or as a sole diet, results in higher rates of weight gain, linear growth, and head growth and a higher risk of developing necrotising enterocolitis. The trial data do not show an effect on all-cause mortality, or on long-term growth or neurodevelopment.
Objective: Necrotizing enterocolitis (NEC) causes significant morbidity and mortality in very low birth weight (VLBW) infants. Our objective was to assess the influence of pasteurized donor human milk (PDHM) on the incidence of NEC. Methods: This is a retrospective chart review of 179 VLBW (< 1500 g) infants born in the pre-PDHM era (January 2001-March 2003) vs 152 born in the post-PDHM era (April 2003-December 2004). Results: The cohorts had similar demographic characteristics. The overall incidence of NEC was 12% in the pre-PDHM era vs 10% in the post-PDHM. Although not statistically significant, surgical NEC decreased from 7% to 3% respectively. Sepsis decreased from 10% to 6% between the pre and post-PDHM eras (p=0.04). Erythropoietin administration for anemia of prematurity was associated with a protective effect for NEC, even after adjusting for gestational age, indomethacin and mother's own milk intake (OR 0.37, 95% CI 0.16-0.85, p=0.02). The introduction of PDHM did not decrease the amount of mother's own milk use. Conclusions: The overall incidence of NEC remained unchanged after the introduction of PDHM in a single neonatal intensive care unit, but the cases of surgical NEC had a trend to decrease. Randomized controlled clinical studies evaluating the effect of PDHM on the severity of NEC are warranted.
Breastfeeding and human milk are the normative standards for infant feeding and nutrition. Given the documented short-and long-term medical and neurodevelopmental advantages of breastfeeding, infant nutrition should be considered a public health issue and not only a lifestyle choice. The American Academy of Pediatrics reaffirms its recommendation of exclusive breastfeeding for about 6 months, followed by continued breastfeeding as complementary foods are introduced, with continuation of breastfeeding for 1 year or longer as mutually desired by mother and infant. Medical contraindications to breastfeeding are rare. Infant growth should be monitored with the World Health Organization (WHO) Growth Curve Standards to avoid mislabeling infants as underweight or failing to thrive. Hospital routines to encourage and support the initiation and sustaining of exclusive breastfeeding should be based on the American Academy of Pediatrics-endorsed WHO/UNICEF "Ten Steps to Successful Breastfeeding." National strategies supported by the US Surgeon General's Call to Action, the Centers for Disease Control and Prevention, and The Joint Commission are involved to facilitate breastfeeding practices in US hospitals and communities. Pediatricians play a critical role in their practices and communities as advocates of breastfeeding and thus should be knowledgeable about the health risks of not breastfeeding, the economic benefits to society of breastfeeding, and the techniques for managing and supporting the breastfeeding dyad. The "Business Case for Breastfeeding" details how mothers can maintain lactation in the workplace and the benefits to employers who facilitate this practice. Pediatrics 2012; 129:e827-e841
Maternal breast milk is the best source of enteral nutrition for preterm or low birthweight infants. With insufficient volumes of maternal breast milk, donor-expressed breast milk (DEBM) or artificial formula are two common alternatives. Despite publication of a recently updated Cochrane review1 demonstrating a decrease in the risk of necrotising enterocolitis (NEC) in babies receiving DEBM compared with those receiving formula, concerns about the methodological quality of some of the included studies, their applicability to current neonatal practices (the majority of included trials were carried out in the 70 s and 80 s), the slower in-hospital growth rates of those on DEBM and the fact that growth-restricted premature infants as well as unwell infants were generally excluded … [Full text of this article]